Provider Demographics
NPI:1205206422
Name:HART, VICTORIA JACOBSEN (PA-C)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:JACOBSEN
Last Name:HART
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:VICTORIA
Other - Middle Name:JACOBSEN
Other - Last Name:HART
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:302 SYLVESTER DR
Mailing Address - Street 2:
Mailing Address - City:YOUNGSVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70592-6656
Mailing Address - Country:US
Mailing Address - Phone:337-298-0227
Mailing Address - Fax:
Practice Address - Street 1:2390 W CONGRESS ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-4205
Practice Address - Country:US
Practice Address - Phone:337-261-8526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-30
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200893363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA200893OtherLIC